What service is it?

The description from the American Medical Association (AMA) describes the visit complexity inherent to evaluation and management services that are part of ongoing care for a patient. CMS believes code G2211 reflects the time, intensity, and practice expense required to build longitudinal relationships with patients and address most of their health care needs with consistency and continuity over long periods of time. The services are part of a comprehensive, continuous relationship between the provider and the patient, often with the provider serving as a focal point for the patient’s care. The patient may be new or established but doesn’t need to have either a single, serious condition or a complex condition. Services may include treatment, management, coordinating care, patient education, shared decision-making between the provider and patient, and shared commitment to achieving goals.

What provider type can use it?

CMS hasn’t restricted the code to certain specialties. The assumption is that some specialties will furnish this service more than others and primary care is where it’s expected to be seen the most. Physicians who rely mainly on office/outpatient E/M visits will report G2211 more than those who perform procedures more than office visits. The code recognizes the resources inherent in holistic, patient-centered, care that combines treatment of illnesses/injuries, management of acute and chronic conditions, and the coordination of specialty care in a relationship with a clinical care team.

Specialists who see a patient over time for a condition for which they have taken responsibility and for which they continue to provide care and treatment should use this code. A urologist who sees a patient every year or multiple times during the year for elevated PSI and prescribes medication may include the G2211 with the E/M Code. A neurologist who evaluates and treats a patient for migraines over several years; trying different medications and tracking prevention techniques, should bill the G2211 with the E/M Code. It should also be used by an endocrinologist who has an ongoing relationship with a DM Type 2 patient to continually track changes and progression with medication changes and patient concerns.

When to use it?

The code must accompany an office or other outpatient E/M service because it’s an add-on code. Here are two scenarios that support the use of G2211:

A patient sees you, their primary care practitioner, for sinus congestion. The provider may suggest conservative treatment or antibiotics for a sinus infection. The provider also decides on the course of action and the best way to communicate the recommendations to the patient in the visit. How the recommendations are communicated is important in that it not only affects the patient’s health outcomes for this visit, but it also can help build an effective and trusting longitudinal relationship between the provider and the patient. This is key so the provider can continue to help the patient meet their primary health care needs.

The complexity that code G2211 captures isn’t in the clinical condition: the sinus congestion. The complexity is in the cognitive load of the continued responsibility of being the focal point for all needed services for this patient. There’s an important cognitive effort in using the longitudinal doctor-patient relationship itself in the diagnosis and treatment plan. These factors, even for a simple condition like sinus congestion, make the entire interaction inherently complex. In this example, the provider may bill G2211.

A patient with HIV has an office visit with their infectious disease physician. The patient tells their physician they’ve missed several doses of HIV medication in the last month because their physician is part of their ongoing care and have earned their trust over time. Their physician tells them it’s important not to miss doses of HIV medication, while making the patient feel safe and comfortable sharing information like this with them in the future.

If the provider didn’t have this ongoing relationship with the patient and the patient didn’t share this with the provider, the provider may have decided to change their HIV medicine to another with greater side effects, even when there was no issue with the original medication. Because their provider is part of ongoing care for a single, serious condition or a complex condition such as HIV, and have to weigh these types of factors, the E/M visit is more complex. In this example, the provider may bill G2211.

When is it NOT supported?

Billing the add-on code is not supported when care is furnished by a provider whose relationship with the patient is of a discrete, routine, or time-limited nature. Examples include removal of a mole, treatment of a simple virus, counseling related to seasonal allergies, the initial onset of gastroesophageal reflux disease, treatment for a fracture, or treatment in which comorbidities are either not present or not addressed. Other examples include situations in which the billing provider has not taken responsibility for ongoing medical care for that patient with consistency and continuity over time, or doesn’t plan to take responsibility for subsequent, ongoing medical care for that patient with consistency and continuity over time.

Medicare clarified that the patient-physician relationship is the primary consideration that will drive the reporting of the code in addition to the E/M visit. They also clarified that if the E/M code reported on the same date of service requires the use of Modifier 24 or 25, then G2211 should not be reported because the extra work required for long term care is covered by the E/M & procedure.

What must be documented?

There isn’t a specific statement that must be included in the chart record like a time statement. It should be apparent in the documentation by the expectation that the patient is coming back for ongoing care. The record should include clear direction and a care plan demonstrating the patient return and continued care for the patient and/or condition. Documentation for an E/M visit for which the focus of the visit is unrelated or not obviously related to the treatment of a long-term care issue which is the reason for the ongoing relationship between the practitioner and the patient must include additional documentation to indicate that the patient is returning to the practice.

In conclusion, this code should be used whenever the provider performs an Evaluation and Management service for a patient with whom they have a longitudinal relationship committed to providing care and treatment for specific conditions. CMS has permanently added this code to the Medicare telehealth list so it can be billed even if the E/M service is performed via an accepted audio and video communications.